Healthcare: Is there only one correct answer?

BY ELIZABETH LI

The United States (US) healthcare system and the European healthcare system are ideologically and functionally different. When it comes to rankings, the US consistently ranks below other countries, such as France, Germany, and the United Kingdom in terms of life expectancy and health-care spending per capita. This disparity in the rankings begs the question: is the European healthcare system better than the US healthcare system? Not only are our healthcare systems different, but the medical training timeline also differs. Could variations even in the way doctors are trained be affecting the overall quality of a country’s healthcare? In order to understand why this disparity might exist, I traveled to three European countries to gain a human perspective on how the European system works and how its differences from the US system affect people’s health.

European Healthcare

Source: Pixabay.

In the European Union, most countries have two kinds of hospitals: those that belong to the private sector and those that are part of the public sector. Hospitals in the private sector are normally not subsidized by the government while public hospitals, which make up the majority of hospitals in Europe, are mostly funded by the government. The government is able to fund public hospitals because citizens pay a separate healthcare tax in addition to the income tax. For example, in Lithuania, people pay a nine percent health tax.

Although most countries follow this system, there are still major differences when it comes to how the population pays for treatment and how people are reimbursed at public hospitals. In France, patients pay for their treatment upfront using a “carte vitale,” a health insurance card, and the state reimburses all or most of the cost within a few days. However, even with the reimbursement, it is common for people to also purchase their own insurance in order to ensure that they are reimbursed 100%. Notably, in Belgium, which follows a healthcare system similar to that of France, alternative treatments such as acupuncture and chiropractic care performed by a qualified doctor also qualify for reimbursement through the government. The majority of the French and Belgian population go to government-funded hospitals for treatment. On the other hand, in Germany, a larger percentage of the population get private insurance. The people who turn to private insurance are usually younger; their premiums cost less because they are theoretically healthier and at less of a health risk than the elderly. Unemployed people or people who earn less than a relatively high threshold are also funded through non-profit organizations.

Finally, the European Union also offers the European Health Insurance Card. This free card allows European citizens to receive medical treatment in emergencies or for preexisting conditions in other countries in the union for free or at a discounted price. Ultimately, because most countries in Europe have universal healthcare, citizens are able to obtain treatment more or less free of charge wherever they travel within Europe.

European Medical Training/Profession

In terms of medical education, European students follow a timeline that allows them to complete all of their medical training (school and residency) in seven to ten years after graduating high school. Different countries have different methods of admitting students into medical school, but all European schools share one thing in common: European students do not earn a bachelor’s degree before applying for medical school. In other words, they progress straight from high school to medical school, which usually lasts six years.

Although the overall education timeline is relatively standardized, certain variations also exist. For example, in France, any high school student may enroll in the first year of medical school. However, in order to proceed to the second year, they must complete an exam at the end of the first year and rank in the top percent of the class.

Furthermore, medical schools have different qualifications in different countries.   According to the Journal of Ethics, medical school admissions officers in most European countries—Greece, Italy, Spain, etc.— “use exclusively academic criteria to select students for the majority of seats available in medical schools.” They look at a combined score of student’s high school GPA and national biology, physics, and chemistry exam scores in order to determine their qualification. However, other regions such as the United Kingdom look at applications on a more holistic level, taking both academic strength and extracurricular activities into consideration.

Similarly, different countries have different methods of placing medical students into residencies. In most countries, there actually is no examination required for admission into a resident program or specialty. Only a few countries, including France, Portugal, and Spain, require medical school graduates to take a national exam first before choosing a specialty. Ultimately, just like their healthcare system, European medical schools follow the same general medical timeline, but slight variations between countries also exist.

US Healthcare

Source: Pixabay.

In contrast to the European healthcare system, the US healthcare system operates mainly through privately-owned facilities, also known as private sector businesses. On a very basic and simplified level, there are essentially three components: the providers, the population, and the insurers. Included in providers are the doctors, nurses, and any other hospital staff who provide healthcare. The population refers to anyone in society who seeks medical attention, whether that be a treatment for a chronic illness, a visit to the hospital for a routine checkup, or simply just to ask a question. Lastly, insurers, as the name implies, mainly consists of insurance companies. There are two ways for the people of the population to obtain insurance: either they pay for their own premium—i.e. their insurance policy—or their employer includes their insurance as a part of their job’s health benefits. Providers receive most of the payment from these insurers. However, insurance companies usually also require the population to pay providers a copay—a small amount out of pocket—for each visit in order to discourage people from visiting the hospital when they do not really need to.

For those who are unable to afford the copay or the insurance—whether that is because they are unemployed or are unable to pay for their own premium, social programs attempt to provide health insurance for these families. The largest of these programs is Medicaid, funded by the state and federal government. In addition, laws have also been passed in order to help more people obtain insurance. For example, the Patient Protection and Affordable Care Act (PPACA), commonly known as Obamacare, passed in 2010 has largely increased the number of individuals who can afford healthcare by increasing health insurance quality but decreasing the cost. Specifically, it is now required for all insurance companies to accept a patient regardless of his or her pre-existing conditions. This is especially helpful for people who may have pre-existing conditions or a family history of a disease because it prevents insurance companies from denying these patients insurance or charging an insanely high premium. Unfortunately, in the US, there is also a social stereotype that public health insurance subsidized by the government is considered “welfare for lazy people” while private health insurance is considered inaccessible. Furthermore, the system is becoming increasingly politicized as different political parties argue for an increase or decrease in taxes.

US Medical Training/Profession

As for medical training, in the US, after high school, it takes anywhere from 11 to 15 years to complete one’s education as a doctor. The timeline begins after high school, extending from undergraduate college/university to medical school and finally to residency. As an undergraduate, students are exposed to a broad spectrum of subjects in both the humanities and the sciences. During their undergraduate years, those interested in applying for medical school must build an application consisting of a strong grade point average (GPA), a variety of extracurricular activities, and a high Medical College Admissions Test (MCAT) score, an exam taken toward the end of college.   If accepted, students continue with another four years of education in medical school. During these formative years, students often learn the core principles of medicine (from books) before completing rotations (in clinics) in their third and fourth years. Although the timeline described above is most common, some variations also exist. For example, it is becoming increasingly common for people to take gap year(s) between undergraduate and medical school. According to US News, students on average begin medical school when they are 24 years old even though most earn a bachelor’s degree by the time they are 22 years old.

After completing medical school and receiving their Doctor of Medicine degrees (MD), students apply to residency programs and, if they are matched with a program, move on to their last stage of medical training. Depending on what specialty students apply for, residencies can last for as little as three years (e.g. family practice) or as long as seven years (e.g. plastic surgery).   At this point, even though they are still technically learning more clinical skills, residents are considered to be employed since they are paid a salary, although not very high.

Finally, after completing all these steps, students finally formally complete their medical education. Although there is a wide range of salaries depending on several factors, such as a doctor’s specialty, location, and hiring hospital, doctors tend to earn a minimum of around $130,000. In the US, doctors are generally well-respected and well-paid.

Methodology

Source: Flickr.

However, these data do not capture the full nuance of how each health system works because these data lack human perspective. Therefore, I traveled abroad this summer to several different countries, including Lithuania, Greece, and Portugal, to find out more about European healthcare and medical training from the people who comprise the healthcare system itself. Part of the time I was abroad, I shadowed doctors in a variety of departments and also managed to interview the hospital staff in various positions. In Vilnius, Lithuania, I interviewed Dr. Sarkinus, a pediatric surgeon. In Athens, Greece, I interviewed Stavros Tsitiridis, a spring nurse working in the cardiac surgery department of Evangelismos Hospital. And lastly, in Terceira, Portugal, I interviewed Rui Duarte Gonçalves Luis, president of the administrative board of Hospital de Santo Espírito.

Interviews took place either in the interviewee’s office or in the operation room before a procedure and lasted for approximately half an hour. In each interview, I centered my questions around three topics: the country’s healthcare system, the country’s medical training timeline, and each respondent’s personal story of how they became a doctor. In the first section, participants described their country’s healthcare system, listed the most prominent strengths and weaknesses of their national system, and commented on the differences—including which system they found superior—between European and US healthcare. Similarly, in the second section, participants described, listed, and commented on the education process for becoming a doctor in their country. The third section sought to shed light on one question, “How did you know you wanted to work in medicine?”

Human Perspectives on Healthcare

When asked about healthcare, the three interviewees had varying opinions. Tsitiridis from Athens believed that making Greece’s healthcare system more privatized would not be beneficial, as hospitals would then no longer have the incentive to accept patients without social security. The way the Greek system currently is set up, theoretically everyone pays for social security and in turn, everyone is able to be hospitalized. However, in reality, many people do not have social security, either because they cannot afford it or do not have a high enough salary. As a result, those who do pay for social are also affected since the taxes they pay must cover not only their own treatment but also the treatment of those who do not have social security. Essentially, Greece has to use the taxes collected from a proportion of the population to support the entire population. This leads to shortages of basic supplies in hospitals and the inability to develop new techniques. In fact, in Greece I witnessed a mitral valve replacement surgery that was done via open heart surgery and involved temporarily stopping the heart and circulating the blood through a heart-lung machine. In the US, due to more advanced technology, most mitral valve replacements are able to be completed simply through a series of small incisions, significantly decreasing recovery time and the chance of infections and other complications.

On the other hand, President Gonçalves Luis from Terceira had mixed feelings about both the European and the US healthcare system. He stated that the biggest hardship hospitals face is the lack of funding from the government. According to Gonçalves Luis, “the difference between private and public [hospitals] is that normally [private hospitals are more efficient].” In other words, people who work in public hospitals are less concerned about saving resources and using them wisely. Gonçalves Luis attributes this behavior to the fact that because public hospitals are not making a direct profit, administrators and employees care less when it comes to how much people use. “If we had another system, like the US, maybe people will [only] go to the hospital when they really need to,” implying that checkups and thus materials are often used in excess.

Furthermore, at the time I was visiting, nurses in the Azores islands—which Terceira is a part of—were striking due to inconsistencies in the number of work hours per week. Gonçalves Luis explained that in the public sector, nurses work 35 hours a week while in the private sector, nurses work 40 hours a week. However, public hospitals in the Azores are starting to become what is known as a “public company,” which means they still belong to the government but must follow private sector rules. During this period of transition, nurses who were hired before the change still work 35 hours, but any nurses newly hired now must work 40 hours. This discrepancy resulted in riots as all nurses, old and new alike, demanded to work the same number of hours per week. This situation occurred because the European healthcare system is comprised of both a strong public and a strong private sector.

In agreement with President Gonçalves Luis from Terceira, Dr. Sarkinus in Vilnius believes that there is no such thing as a better system. All patients know that their treatment will be paid for, even if they cannot pay for it themselves. Consequently, Lithuania faces a problem with people coming to the hospital for very minor treatments that could have been taken care of at home. According to Dr. Sarkinus, “I think the best is [a mix of both healthcare systems]; you pay as a tax, for example for emergency help, and then the insurance comes in later.”

Second Question: Medical Training

As for medical training, all three interviewees agreed that people become doctors in Europe and the US in roughly the same timeframe, despite differences in education timelines. US doctors who do not take gap years or complete alternative programs earn their MD at the earliest age of 29. In Europe, doctors can earn their degrees by the time they are 27. To make things even faster, Dr. Sarkinus believes that medical school in Europe could be even shorter. In his experience, “the last two years in [medical school] were actually a waste of time […] lots of people [have more time and] start entering their second specialties—for example chemistry, math, law, etc—during those years. This means that the studies can be a little shorter at the university and you can save a year or so.” Ultimately, because students in Europe do not attend undergraduate for four years, they earn their degrees a little earlier, but not much. This minute difference in age seems to be inconsequential and likely does not significantly affect their performance as a physician.

Third Question: Social Issues

Only Dr. Sarkinus in Vilnius shared why he became a doctor. Dr. Sarkinus says his family and society’s stereotypes had a big influence on his decision to become a doctor. “My aunt, she told me that if you are a doctor, you will be respected for your entire life and that it’s a good specialty. You always will have work and you can live and have money. But I was fooled because it is not like that.”   At least in Lithuania, being a doctor does not guarantee financial stability. As a pediatric surgeon with ten years of experience, Dr. Sarkinus says he earns 800 Euros, approximately 870 USD, a month after all taxes are accounted for. In comparison, pediatric surgeons in the US earn up to 40,000 USD a month. “In the normal world, everywhere it’s different; all of the doctors, teachers, policemen, firemen, they all get very well paid. But it’s not like that in Lithuania,” says Dr. Sarkinus. In fact, people in each country I traveled to shared a common belief that doctors are underpaid.

Conclusion

Ultimately, it does not seem like one healthcare system is decisively better than the other. In addition, the different styles of training doctors do not seem to be play a role in the different problems that the US and European healthcare systems face. Despite the fundamental differences that exist between the US and European healthcare systems, each system could benefit from adopting practices of the other. In other words, each system must improve, but in different ways. Crafting a flawless healthcare system is immensely complex, but one place to start could be by incorporating elements of the “opposite” healthcare system. Finding the perfect balance between the public and private healthcare may very well be the resolution to the issues faced by both systems.

Elizabeth Li is a sophomore in Morse College majoring in Molecular, Cellular & Developmental Biology. She can be contacted at elizabeth.li@yale.edu.

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References:

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